The Times They Are a-Changin’

We must build an infrastructure and commit resources to respond to a fluid political climate.

In May 2016, I became chair of the ACR Commission on Economics, inheriting a group of dedicated volunteers. One message I communicated to our team at that time was that shifts in socioeconomic policy are not only inevitable, but also hard to predict. Therefore, we must build and maintain processes and infrastructure to respond. Three years later, it is worth reviewing where and how socioeconomic policy has changed and how our actions and direction have been affected.

Healthcare policy is crafted on multiple fronts. At the most basic level, Congress passes laws and the president endorses those laws and implements them through regulations and subregulations. Elected officials change. Those responsible for crafting certain laws may be different from those representatives charged with implementation. When policy goals differ between these two groups, unpredictable policy directions may follow. In this column, I discuss how healthcare policy has been affected by political changes at the highest levels of the federal government over the past three years.

The two most significant pieces of healthcare legislation over the past decade are the Patient Protection and Affordable Care Act (ACA) and MACRA, both of which were signed into law by a Democratic president. The ACA passed Congress largely along party lines — supported by the Democrats and opposed by the Republicans. MACRA was bipartisan and bicameral. In 2016, our focus was on the evolving regulations and implementation requirements of those laws. That year was also an election year. While the future control of Congress was uncertain, most experts predicted that the Democrats would maintain control of the White House. This control meant that the executive branch would continue to advance the ACA, or at least not allow actions that would stymie or reverse it. The same confidence in MACRA’s advancement was assumed.

The political landscape changed quickly in late 2016. A new Republican president was elected, and he spent his first two years with Republicans controlling both the Senate and the House. Over those two years, we saw significant slowing in ACA and MACRA implementation, compared with what would likely have occurred under a Democratic president and Congress. For instance, the ACA individual insurance mandate, ACA-mandated insurance risk corridors, and the Independent Payment Advisory Board are now gone. MACRA — mandated for full implementation by 2019 and promising an aggressive timeline for alternative payment model development — has slowed considerably. This MACRA slowing is due to not only regulatory actions but also to the Bipartisan Budget Act of 2018 — the signature legislative achievement of the current administration. PAMA, which included the Appropriate Use Criteria mandate during the ordering of advanced diagnostic imaging, has also fallen behind its statutorily mandated timeline. In the case of PAMA, full implementation was originally required for 2017. That has now been delayed until 2021.

The slowing of these policies impacts our directions and actions. For instance, ACA, MACRA, and PAMA all require extensive interaction with CMS and other regulators regarding the necessary regulations for implementation. In addition, we must provide our members with education and tools for success. Those members, accordingly, must dedicate their own resources toward implementation. The required effort and monetary commitment can be significant, and the return on investment is uncertain against a backdrop where the laws and regulations can change overnight.

Things changed again in 2018. The midterm election saw the U.S. House of Representatives flip back to the Democrats. This makes it unlikely that a legislative reversal of the ACA will follow (although the judicial branch may rule the ACA unconstitutional). MACRA remains generally supported, since few policymakers wish to revisit the annual physician payment reductions brought about by the sustainable growth rate formula that MACRA replaced. You may recall that MACRA includes a five-year physician pay freeze from 2020 to 2025. During that freeze, operational expenses for physicians will continue to increase and it is possible there will be calls from the house of medicine for relief. Radiology will be part of those discussions.

Where does this leave us in 2019? A new election season has already started. Again, the control of Congress and the White House hang in the balance. This brings me back to my earlier point: changing political directions are hard to predict. We must build an infrastructure and commit resources in a manner that prepares us to respond to a fluid political climate. The Commission on Economics is continuing its commitment to do just that.